Ian Frampton

The fault is not in her parents but in her insula--a neurobiological hypothesis of anorexia nervosa.

The reported abnormalities of brain function in anorexia nervosa (AN) include impairment of neural circuits involving cortical (orbito-frontal, somatosensory and parietal) and sub-cortical (amygdala, hippocampus, thalamus, hypothalamus and striatum) structures. The insular cortex serves an integrative function for all the structures relevant to the features of AN and as such may be central to this impairment. We hypothesise that a rate limiting dysfunction of neural circuitry integrated by the insula can account for the clinical phenomena of AN. Such dysfunction could account for the known psychopathology, neuroimaging abnormalities and neuropsychological deficits. Proposals to test this hypothesis are made.

Assessing emotion recognition in 9–15-years olds: Preliminary analysis of abilities in reading emotion from faces, voices and eyes

Primary objective: Little is known about how emotion recognition abilities develop during childhood and adolescence, although adolescence is a time marked by significant changes in socio-emotional behaviour. The first aim of this study was to explore the range of emotion recognition skills that 9–15-year olds would normally display and whether emotion-reading skills are reliably measurable. Secondly, one wanted to determine whether adolescence is a period during which skills in recognizing emotions improve. Methods and procedures: Novel and adapted measures of emotion processing were used in tasks that required 67 9–15-year olds to read emotion from voices, eyes and faces. Main outcomes and results: Findings indicate that emotion recognition abilities are reliably measurable skills. A stage of improvement in facial expression recognition and reading emotion from eyes was found to occur at ∼11 years of age. Conclusions: The findings show that these skills can be measured and that it is possible to devise assessment tests which are sensitive to developmental improvements in emotion recognition skills in early adolescence, when screening for the effects of child brain injury.

Anorexia nervosa and the insula.

Anorexia nervosa is a serious illness with major physical and psychological morbidity. It has largely been understood in terms of cultural and environmental explanations. However these are insufficient to explain the diverse clinical features of the illness, nor its rarity given the universality of sociocultural factors. Over the last 20 years, there has been a steady accumulation of neurobiological evidence requiring a re-formulation of current causal models. We now offer a new empirically-derived hypothesis implicating underlying rate-limiting dysfunction of insula cortex as a crucial risk factor for the development of anorexia nervosa. Supporting evidence for this hypothesis is drawn from anatomical and clinical research of insula cortex damage in humans and neuroscientific studies of relevant clinical features including taste, pain perception and reward processing. This hypothesis, if sustainable, would be the first fully to explain the disorder and predicts promising novel treatment possibilities including Cognitive Remediation and Motivation Enhancement Therapies. The knowledge that the challenging behaviours, so characteristic of AN, are the result of underlying cerebral dysfunction, rather than being purely volitional, could help to reduce the stigma patients experience and improve the therapeutic alliance in this poorly understood and difficult to treat disorder.

Reading emotions after child brain injury: a comparison between children with brain injury and non-injured controls.

Primary objective: Child brain injury can have a lasting, detrimental effect upon socio-emotional behaviour, but little is known about underlying impairments that cause behavioural disturbance. This study explored the possibility that a proportion of difficulties result from compromise to systems in the brain which function in reading emotion in others from eyes, face expression or vocal tone. Methods and procedures: Measures of ability in reading emotion from faces, voices and eyes were used in conjunction with a battery of tests of cognitive function, in gathering data from 18 children aged between 9–17 with acquired brain injuries (ABI). Performance levels were compared against the normative data from 67 matched ‘healthy’ children. Questionnaires were used as a measure of socio-emotional behaviour. Main outcomes and results: The ABI children in the sample were worse than their same age peers at reading emotions. Regression analyses revealed that emotion recognition skills and cognitive abilities were generally unrelated. Some relationships between emotion reading difficulties and behaviour disturbance were found, however there were limitations associated with this particular finding. Conclusions: Emotion-recognition skills, which are not routinely assessed following child brain injury, can be adversely affected as a consequence of brain injury in childhood.

The Neuropsychological Profile of Children, Adolescents, and Young Adults with Anorexia Nervosa

The neuropsychological profile of a sample of 155 patients with a clinical diagnosis of anorexia nervosa was assessed using a test battery specifically developed for such patients. The current findings suggest that the patients display a common neuropsychological profile including both strengths and weaknesses when compared with published norms. The patients displayed good verbal fluency skills, but performed poorly on tests of visuospatial memory, associated with relatively weak central coherence. They were within the average range on the assessment of executive functioning except for one measure of set-shifting. This study provides a valuable point of reference for clinicians when considering treatment options.

The Development of Emotion and Empathy Skills after Childhood Brain Injury.

Lasting socio‐emotional behaviour difficulties are common among children who have suffered brain injuries. A proportion of difficulties may be attributed to impaired cognitive and/or executive skills after injury. A recent and rapidly accruing body of literature indicates that deficits in recognizing and responding to the emotions of others are also common. Little is known about the development of these skills after brain injury. In this paper we summarize emotion‐processing systems, and review the development of these systems across the span of childhood and adolescence. We describe critical phases in the development of emotion recognition skills and the potential for delayed effects after brain injury in earlier childhood. We argue that it is important to identify the specific nature of deficits in reading and responding to emotions after brain injury, so that assessments and early intervention strategies can be devised.

An examination of the ravello profile--a neuropsychological test battery for anorexia nervosa.

The Ravello Profile test battery was developed to ensure a consistent methodology when researching neuropsychological functioning in anorexia nervosa (AN). To date, 157 patients with AN have been assessed with the full Ravello Profile. The present review is the first study to systematically investigate the tests included in the battery. Fifteen experimental studies, comparing AN patients with healthy control participants on at least one of the Ravello Profile tests, were identified, and effect sizes were calculated. Three of the tests, Verbal Fluency Test (VFT), Rey Complex Figure Test (RCFT) and Trail Making Test (TMT), were meta-analysed, and the pooled standardized effect size was significant for all three tests (0.25, -0.68 and 0.49, respectively). Patients with AN performed significantly better than healthy control participants on assessment of verbal fluency (VFT) and worse on tests of visual memory (RCFT) and set-shifting (TMT). The Ravello Profile test battery appears to consist of tests that are appropriate for assessing characteristic neuropsychological profiles specific in AN.

Anorexia nervosa – A noradrenergic dysregulation hypothesis

Anorexia nervosa manifests a wide range of features which cannot fully be explained on the basis of socio-cultural pressures to be thin, nor by starvation, nor dehydration. Evidence is emerging of a significant neurobiological contribution to its aetiology. However there has to date been no explanation for its pathogenesis that integrates the previously identified genetic, neurobiological and socio-cultural contributing factors. In this paper we propose an empirically-based hypothesis that genetically determined noradrenergic dysregulation, interacting with epigenetic factors, leads to high levels of anxiety, impaired neuroplasticity and regional cerebral hypoperfusion. These, in combination, lead to insula dysfunction. The resulting impairment in insula homuncular representation explains the pathognomonic body image distortion. This distortion, combined with high levels of body-focused anxiety, gives rise to intense dieting, noradrenergic precursor depletion, and initial reduction in anxiety. The subsequent rebound exacerbation of anxiety leads to a vicious cycle of maintenance. Novel treatment implications based on this hypothesis are briefly considered.

A case series investigating distinct neuropsychological profiles in children and adolescents with anorexia nervosa.

A number of specific deficits in neuropsychological functioning in anorexia nervosa (AN) have been identified. However, it is not known whether these specific deficits cluster together to form one or more clear neuropsychological profiles. We present a case series of nine participants who were recruited as part of a wider, ongoing investigation of the neuropsychological profile of eating disorders (the Ravello Profile). Results show that there was a wide range of different neuropsychological profiles at initial assessment. This suggests a spectrum of neuropsychological strengths and weaknesses that would otherwise be masked in a cohort analysis. It is anticipated that factor and cluster analytic studies will establish one or more common profiles of neuropsychological deficits in AN.

Reading emotions after childhood brain injury: Case series evidence of dissociation between cognitive abilities and emotional expression processing skills

Primary objective: A previous study has shown that children with brain injuries are worse than their same age peers at reading emotions. It has not clearly been established that cognitive impairments and emotion processing impairments are dissociable in children and the question of whether emotion-reading skills can be selectively impaired in children after brain injury is explored here. Research design: This study addresses this issue by testing a case series of seven children with brain injuries, who were identified as experiencing emotional or behavioural difficulties, according to a social-behavioural measure. Methods and procedures: A battery of tests of cognitive function and measures that assess ability in reading emotions from faces, voices and eyes was administered to each child. Main outcomes and results: Some cases demonstrate broadly based deficits that affect both cognitive and emotion processing domains, whilst other cases demonstrate highly selective deficits in reading emotions. Conclusions: Based on the profile of results across the cases, this study reports that modality-specific, selective impairments in reading emotional expression can be found in children after brain injury. In addition, the data provide evidence of dissociation between cognitive abilities and emotional expression processing.